NUR 243 Exam 1 UPDATED ACTUAL Questions and CORRECT
Answers
What Clinical Judgment is Used for -Nurses use clinical judgement for everything
-Things they have to critically think about
Ex: Making task assignments
-Nurse might not use clinical judgement for:
1. Things you do subconsciously
2. Something you do without thinking
3. Routine, standardize procedures that have clear guidelines and do not require
adaptation based on individual patient needs
Ex: taking vital signs using a standard protocol or administering a pre-measured
medication according to a standing order
Tanner's Model of Clinical Judgement 1. Noticing
2. Interpreting
3. Responding
4. Reflecting
Noticing -Gathering data & noticing information, looking for patterns
Interpreting -Processing information
-Identify problem
-Relevant vs irrelevant data
-Make deductions or form opinion based on your analysis
Responding -Select course of action
-Determine priority
-Criteria to evaluate actions
Reflecting -Collect evaluation data, determine if situation has improved.
-What went wrong?
-What went right?
-Change in the future?
**Reflecting can be in action or on action:
In action: evaluate as you are responding
On action: evaluate after situation is over
Delegation -The process for a nurse to direct another person to perform nursing tasks and
activities
-A transfer of responsibility rather than authority.
**The RN is still accountable**
, 5 Rights of Delegation 1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision/evaluation
Questions to Guide Delegation -Is the task within the scope of practice?
-Is the task in accordance with established institutional policies?
-Does the person possess competency to perform the task safely?
-Can the patient's safety be maintained?
-Does the task require specialized nursing knowledge or judgment?
RN Responsibilities -All new or unstable patients
-Initial teaching
-Analyze data
-Plan of care
-Diagnose
-Evaluate care
-IV push medications and IV drips
-Blood
-TPN
-Performing all tasks that are invasive and/or sterile
*The RN can delegate to another RN, LPN, and UAP*
What the RN Cannot Delegate - Assessment, evaluation or monitoring
- Pre-op assessment or post-op assessment
- Handling invasive line or sterile technique
- Patient initial education
- Triage
- Planning, care plans, interventions or nursing diagnosis that falls out of the
scope of practice for who activities are being delegated.
- To a nurse practitioner or physician
Delegation from RN To LPN -Medications including piggybacks but not usually IV meds or IV drips
-Can monitor IV fluids
-Dressing changes
-Wound irrigation
-Suctioning
-Catheterization
-Reinforce teaching
Delegation to UAP -Bathing
-Ambulating
-Transporting
-Repositioning
-ROM
-Vital signs for stable patients (Under RN supervision)
-Obtain specimens like blood glucose, urine, or stool samples
-Feed the patient but not the first feeding or people who have feeding difficulties
(breathing difficulty, paralysis, or difficulty swallowing)
Prioritization Deciding which needs or problems require immediate action and which ones
could tolerate a delay in action until a later time because they are not urgent
Answers
What Clinical Judgment is Used for -Nurses use clinical judgement for everything
-Things they have to critically think about
Ex: Making task assignments
-Nurse might not use clinical judgement for:
1. Things you do subconsciously
2. Something you do without thinking
3. Routine, standardize procedures that have clear guidelines and do not require
adaptation based on individual patient needs
Ex: taking vital signs using a standard protocol or administering a pre-measured
medication according to a standing order
Tanner's Model of Clinical Judgement 1. Noticing
2. Interpreting
3. Responding
4. Reflecting
Noticing -Gathering data & noticing information, looking for patterns
Interpreting -Processing information
-Identify problem
-Relevant vs irrelevant data
-Make deductions or form opinion based on your analysis
Responding -Select course of action
-Determine priority
-Criteria to evaluate actions
Reflecting -Collect evaluation data, determine if situation has improved.
-What went wrong?
-What went right?
-Change in the future?
**Reflecting can be in action or on action:
In action: evaluate as you are responding
On action: evaluate after situation is over
Delegation -The process for a nurse to direct another person to perform nursing tasks and
activities
-A transfer of responsibility rather than authority.
**The RN is still accountable**
, 5 Rights of Delegation 1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision/evaluation
Questions to Guide Delegation -Is the task within the scope of practice?
-Is the task in accordance with established institutional policies?
-Does the person possess competency to perform the task safely?
-Can the patient's safety be maintained?
-Does the task require specialized nursing knowledge or judgment?
RN Responsibilities -All new or unstable patients
-Initial teaching
-Analyze data
-Plan of care
-Diagnose
-Evaluate care
-IV push medications and IV drips
-Blood
-TPN
-Performing all tasks that are invasive and/or sterile
*The RN can delegate to another RN, LPN, and UAP*
What the RN Cannot Delegate - Assessment, evaluation or monitoring
- Pre-op assessment or post-op assessment
- Handling invasive line or sterile technique
- Patient initial education
- Triage
- Planning, care plans, interventions or nursing diagnosis that falls out of the
scope of practice for who activities are being delegated.
- To a nurse practitioner or physician
Delegation from RN To LPN -Medications including piggybacks but not usually IV meds or IV drips
-Can monitor IV fluids
-Dressing changes
-Wound irrigation
-Suctioning
-Catheterization
-Reinforce teaching
Delegation to UAP -Bathing
-Ambulating
-Transporting
-Repositioning
-ROM
-Vital signs for stable patients (Under RN supervision)
-Obtain specimens like blood glucose, urine, or stool samples
-Feed the patient but not the first feeding or people who have feeding difficulties
(breathing difficulty, paralysis, or difficulty swallowing)
Prioritization Deciding which needs or problems require immediate action and which ones
could tolerate a delay in action until a later time because they are not urgent
